2.7a Pain, Sleep Flashcards
Discuss the importance of accurate pain assessment
Pain assessment:
Pain is subjective and has a personal meaning
Pain is real
Pain is the most common reason clients seek healthcare
PQRST review:
Precipitating factors: what is bringing about this pain?
Quality: what does it feel like? How would you describe it?
Region: where does it hurt? Does it radiate anywhere?
Severity: how bad does it hurt? Use appropriate pain scale
Timing: when did the pain start? Does anything make it better?
Unidimensional: sensory experience of pain, pain based on sensation
Multidimensional: pain with social impacts & coping strategies, cultural
Discuss pain theories that explain the neurophysiological basis of pain and pain relief
Specificity and pattern theories explain the neurophysiologic basis of pain by stating that a variety of nerve impulses terminate in the pain centers within the forebrain.
Gate-control theory was formulated in the 1960’s with the idea that the gate in the dorsal horn of the spinal cord blocks pain transmission of small-diameter fibers when large-diameter fibers (faster) carrying touch impulses dominate.
Neuromatrix theory was developed after identifying that the gate-control theory wasn’t complex enough to explain pain. According to this theory, a complex network of neurons is affected by genetic factors and sensory experiences such as visual interpretation, attention, expectation, personality, culture, religion, and stress regulation.
Sensitizing of the the central and peripheral nervous system is another theory that describes painful signals as a series of changes in the nervous system that increases peripheral and central neuron responsiveness. There has been value found in preventing sensitization (inflammation that follows an injury) and treating individuals perceived pain. It is found to reduce the need for more pain medications at a later time
Discuss guidelines that should be followed with analgesia pain management
Analgesic Pain Management Guidelines:
The opioid crisis in the US has led to quickly evolving guidelines used for the use of analgesic medication to treat pain in a variety of pt situations
Previously, the World Health Organization had crated an analgesic ladder for selecting analgesic for pain management and it has been updated over time
Multimodal analgesia (MMA) is the use of non-opioids (typically NSAID’s) with opioids and non-pharmacological techniques to treat pain
Review The Joint Commission’s standards relation to the opioid crisis
The Joint Commission’s Standards:
Patient’s have the right to have relief of pain and agencies are held to standards in order to protect the patient right
Goal: reduce the use of opioids and the associated risks: physical dep, emotional dep, misuse on street, given to family.
Clinical leadership team for treatment of pain
Engagement of the interprofessional team in order to improve pain assessment and management
One complimentary pain treatment modality must be offered
Access to prescription drug monitoring programs
Improved pain assessment, focus on physical functioning
Engage patients in pain treatment decisions
Educate patients on the storage and disposal of pain medications, specifically opioids
Opioid addiction referral programs
Compare chronic and acute pain
Acute pain:
Sudden onset
Caused by actual or potential tissue damage
Sympathetic nervous system response (increased HR, BP, RR, sweating, nausea)
Muscle spasms
May have associated anxiety and/or fear
Managed with short term therapy (analgesics) and treatment of the underlying problem
Chronic pain:
Persists after acute injury is resolved (>3 months)
Caused may not be identifiable. May result from nerve damage or pain modulation mechanism imbalance
Depression and insomnia common
May experience fixation/preoccupation with pain
Management often requires a multidisciplinary approach
Describe the interdisciplinary approach to pain management including complementary therapies
PAIN CLINIC
Common for chronic pain
Team of healthcare professionals who collaborate to utilize pharmacologic and complimentary therapies (Vit, herbs, acupuncture, biotherapy hypnosis, psychotherapy, nutritional supplements and message)
PALLIATIVE CARE:
Management of disease processes in order to improve quality of life.
Focus on relieving physical, mental and spiritual distress due to incurable illness
HOSPICE:
Comprehensive and coordinated care
Pain management in end of life care
Describe how to access equianalgesic table to compare recommended dose of various opioid analgesics
**See ppt page 15
Review patient controlled analgesia
Patient controlled analgesia (PCA):
Used for acute pain, commonly post operative
Bolus dose means pt pushed button to receive set dose
Basal rate means there is a continuous dose per hour but this is not commonly used due to risk of resp depression
Nurse review pt history of pump used for attempts compared with pain relief
PCA is tapered and transitioned to PO meds
No family/friends push button, only pt
Describe nursing assessments for a patient with continuous epidural infusion and identifying medications most commonly used
Continuous Epidural Infusion:
Intraspinal or intrathecal infusion with the tip of catheter placed as close to nerve causing pain
Place thoracic or high lumbar
Utilized for management of chronic intractable malignant pain and post-op pain
Meds: morphine, fentanyl, hydromorphone. NO other narcotics allowed. Have naloxone available
Bupivacaine may be used to provide local anesthetic into the epidural space
NI:
Check orders, assess setup, dressing, monitor closely for sedation and motor function
Pain: use appropriate scale
Sedation: RASS
Motor: Bromage scale (0-3), no block to no movement scale. We want pt to have some movement/sensation
Benefits:
Pain relief more controlled with smaller doses
Earlier bowel recovery
Earlier mobility
Risks: Resp depression/failure Epidural abscess or hematoma Neurologic damage and/or decreased LOC and/or CSF leak Urinary retention Catheter displacement/migration Infection High alert label on tubing, NO IV dosing
Explain monitored anesthesia care (MAC)
Monitored Anesthesia Care (MAC):
Maximal depth of sedation provided by an anesthesia care provider
Requires a consent
Should be NPO if scheduled
Common medications include sedatives, hypnotic, analgesics and other anesthetic drugs
Cardiac monitor, vitals, pulse ox, ETCO2, RASS, pain
Need recovery time
Discuss complications of spinal anesthesia
Spinal Anesthesia:
Anesthetic medications administered in single dose injection into epidural space
Effective for about 90 min and used for surgery of low ab, perineum, lower extremities
Decreased BP may be side effect
CSF leas if a risk: HA most common
Compare and contrast anxiolysis and conscious sedation and related nursing assessments
ANXIOLYSIS:
LOWEST level of sedation leaving no airway, breathing or circulatory effects
Normal response to voice and pain
Impaired coordination and cognitive ability
Quick recovery
Meds: nitrous oxide, IM versed, PO/IM benzodiazepines
Commonly used for MRI due to claustrophobia
CONSCIOUS SEDATION:
MODERATE sedation with patient airway and adequate ventilation
Purposeful response to voice and pain
Circulation is typically maintained but can be compromised
There is reduced fear, anxiety, pain
Quick recovery
Short acting sedatives: versed, fentanyl, propofol
Resuscitation equipment must be available
Trained nurse may admin
Commonly used for laceration repair, joint reductions, GI scopes
Physiology of Pain
Nociceptors are nerve receptors for pain located in tissues throughout the body except for the brain
Tissue containing nociceptors are activated by a noxious stimuli:
Chemical: ischemia, tissue trauma, inflammation
Mechanical: spasm, compression, muscle stretch/contraction
Thermal: extreme heat/cold
Central: stems from damage within the CNS
Myofascial: skeletal muscle pain
Neuropathic: CNS or PNS dysfunction causing pain without injury
Phantom: associated with a missing body part
Psychogenic: physical pain with psychological causes
Radicular: inflammation or compression of a spinal nerve root
Somatic: from skin, ligament, muscles, bones or joints
Vascular: associated with dilation or constriction of blood vessels
Visceral: as a result of inflammation or obstruction of internal organs
Pain scales
0-10 pain scale, numeric rating
FACES pain scale, Wong-Baker, helpful for children or non-verbal
FLACC scale, used with children/infants or mental cognitive issue
PAINAID scale, used most often with dementia patients, can also be used with children
BPS, behavioral scale, ventilated patients
Critical Care Pain Observation Tool, used in ED, intubated, ventilator, IV sedation/pain control
